Occupational violence in nursing:An analysis of the phenomenon of code grey/black events in fourVictorian hospitalsFebruary 2005

Occupational violence in nursing:An analysis of the phenomenon

of code grey/black events in fourVictorian hospitals

February 2005

Published by Policy and Strategic Projects Division, Victorian GovernmentDepartment of Human Services, Melbourne, Victoria, Australia.

February 2005

Copyright State of Victoria, Department of Human Services, 2005.

This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

Also published on www.health.vic.gov.au/nursing

Authorised by the State Government of Victoria, 555 Collins Street, Melbourne.

Printed by: Big Print, 520 Collins Street, Melbourne 3000

Occupational violence in nursing: An analysis of the phenomenon iiiof code grey/black events in fourVictorian hospitals

February 2005

Acknowledgements v

Executive summary viBackground and aims vi

Methodology vi

Major Findings vi

Considerations vii

Definitions of terms and abbreviations used in this report viii

Section 1: Introduction and scope 1

Background 1

Study aims 2

Research methods 2

Report structure 3

Section 2: A critical analysis of the literature pertaining to occupational 7violence in nursingIntroduction 7

Prevalence 7

Measures of violence 8

Predicting risk 10

Influences 12

Management 17

Implications of the literature review for this research 19

Section 3: A prospective audit of internal security responses to violent patient 20behaviour in four Victorian hospitalsIntroduction 20

Setting 20

Hospital A 20

Hospital B 22

Hospital C 23

Hospital D 24

Security audit 25

Nurse audit 30

Contents

iv Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in fourVictorian hospitalsFebruary 2005

Section 4: Staff perceptions of patient aggression 37Introduction 37

Method 37

Participants and setting 37

Instrument 37

Ethics 37

Analysis 37

Results 37

Section 5: Discussion 58

Prevalence of occupational violence across three major metropolitan and one regional health care agency 58

Aggressor characteristics and specific client groups that are more susceptible to being involved in violent 59incidents within the workplace

Implications for best practice to improve the management of patient violence 61directed towards nurses and other health care staff A clear statement of expected behaviour 61

Standardisation of codes grey/black across the acute care sector 61

Uniform collection of core demographic and clinical data 61

Each acute care agency establish a multi-disciplinary code grey/black committee 62

Aggression management training for clinical and security staff 62

Evaluation of training 62

Conclusions 63

References 64This project was funded by the Victorian Department of Human Services Public Health Research Projects 2003 for NursingPractice Research.

Occupational violence in nursing: An analysis of the phenomenon vof code grey/black events in fourVictorian hospitals

February 2005

The project was overseen by principal researchers:

Dr Marie GerdtzDr Phil MaudeAssociate Professor Nick Santamaria

Associate investigators:

Mr Rod MannMs Elizabeth VirtueMs Susan CowlingMr Phillip CattersonAssociate ProfessorTracey Bucknall

Research assistants:

Ms Marianne CroweMs Carola HullinMs Allison HutchinsonMs Catherine Robinson

Statistical consultation:

Dr Michael Bailey

The research team worked in close consultation with the project advisory group, which included representatives from The Alfred, Ballarat, Royal Melbourne and St Vincents hospitals:

Mr Simon BlakesonMs Chris MurphyMs Karen FlettDr Jonothan KnottMr Hugh MorrisMs Sharon PerryMr Garry Robertson

The research team gratefully acknowledges the support of management at The Alfred, Ballarat, Royal Melbourne and StVincents hospitals and the many clinicians who willingly gave up their time to participate in the study.

Acknowledgements

vi Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in fourVictorian hospitalsFebruary 2005

Executive summary

Background and aimsNurses, by virtue of the central role they play within the health care team, are particularly vulnerable to abuse from clientsand their friends or relatives. Indeed, nurses have been identified by the Australian Institute of Criminology as theoccupational group most at risk of violence in the workplace (Graycer 2003). Poor perceptions of health services by patients,altered or disturbed mental states and exposure to prolonged physical or psychological discomforts have been cited as majorcontributors to client initiated violence in hospitals (Perrone 1999).

This study seeks to explore occupational violence in nursing by examining events in which nurses activate a hospital-widesecurity response to actual or potential violence (code grey/code black events). To this end, the research aims to:

describe the prevalence and impact of code grey and code black events in three Melbourne metropolitan health careagencies and one regional centre

identify situations and specific patient groups more susceptible to being involved in violent incidents within the workplace

identify best practice in the management of patient violence and aggression directed towards nurses and other healthcare staff.

MethodologyIn addressing the above research aims, this study employed a mixed method design combining key stakeholder and clinicianinterviews with prospective audit of incidents of actual or potential episodes of aggressive behaviour where an internalhospital-wide security response was activated.

Major findings

Operational issues

Considerable variability in defining responses to violent or aggressive behaviour was evident across the fourparticipating organisations.

Clinical responses to violence or aggression are managed at four different levels, according to the nurses assessmentof the severity of the response.

A comparison of data collected by security and nursing staff reveals that nurses vastly under-report occupational violence.

Prevalence

Across the four settings, 2,662 potential or actual aggressive events occurred over a six-month period. That is an averageof 14.6 events per day.

In the majority of instances where a hospital-wide security code was activated, the aggressor was a client/patientof the service.

Influences

Male gender, history of violent or aggressive behaviour and being under the influence of drugs and alcohol were alsocommon characteristics of aggressive clients in this study.

Significant differences were detected between hospital location and code type. Proportionally higher numbers of codeblack events were found to occur in the regional location than in the metropolitan area.

Significant associations were identified between code type and clinical area. Notably, over half of all internal securityresponses to actual or potential violence occurred in the emergency department.

Occupational violence in nursing: An analysis of the phenomenon viiof code grey/black events in fourVictorian hospitals

February 2005

Considerations

A clear statement of expected behaviour

All persons entering an acute health care facility should receive clear information outlining what is acceptable behaviour.

Standardisation of codes grey/black across the acute care sector

Standard categories and definitions for team responses to violence be developed and implemented across the acute care sector.

Uniform collection of core demographic and clinical data

Uniform collection of hospital-wide security responses be developed that accurately describes the event in terms of both its clinical and security features.

Formation of multidisciplinary code grey/black committees

In each acute care facility, management should establish and maintain workplace committees, comprising members ofclinical staff, security, occupational health and safety and management, to oversee policy development, reporting, monitoringand training of staff for code grey/black events.

Aggression management training for clinical and security staff

All clinical and security staff require aggression management training during orientation to a new acute health facility.

Evaluation of training

To contain the growing problem of occupational violence in nursing, evaluation of existing violence management programsthat appraise cost, sustainability, skill and knowledge retention and effectiveness is essential.

viii Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in fourVictorian hospitalsFebruary 2005

Definitions of terms and abbreviations

Code grey

A hospital-wide internal security response to actual aggressive behaviour.

Planned code grey

A hospital-wide internal security response to potentially aggressive behaviour.

Code black

A hospital-wide internal security response to actual or potential aggression involving a weapon or serious threat to personal safety.

Occupational violence

Includes situations where employees and other people are threatened, attacked or physically assaulted at work. Non-physical violence, such as verbal abuse, intimidation and threatening behaviour, may also significantly affect